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����.� � ., ..,, � <br />��...., � .,�o ..� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-703G <br />Massage Therapist License <br />�� New License ❑ Renewal <br />1. Full Legal Name (Please Print) <br />rr a��, <br />2. Home Address _ <br />(Street) � <br />3. Telephone <br />4. Date ofBirth (�n,n/dd/yyyy)_ <br />5. Email Address <br />6. Driver's License Number <br />7. Ethnicity: <br />8. Sex: <br />Fo the License Year Ending June 30, �� <br />r,, <br />� f � t� �' , ��-� �7 i. _� i , �� � <br />i ...,.+. �,,,�: a a, .. <br />(City) � a � (State) <br />� Cell ❑ Home ❑ Worlc <br />State of Issuance_ <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />❑ Yes �,No If Yes, List each full name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect�to be employed: <br />11. Have you held any previous massage therapist licenses? If yes, in which city were'you licensed? <br />` , <br />�Yes 1 �-h►�,r _� -��� ❑ No <br />(Zip) <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not <br />renewed? If yes, explain in detail on the back of this page. <br />❑ Yes �] No ❑ N/A <br />The information that you are asked to provide on the application is classified by State law as either public, private or <br />confidential. All data, with the exception of driver's license numbers, will constitute public record if and when the license is <br />granted. Our intended use of the information is to perform the background check procedures required prior to license issuance. <br />If you refuse to supply the information, the license application may not be processed. <br />By signing below you certify that the above information is correct and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: Back�round checks ma t�p to 30 days to complete.) <br />�; ...� r j <br />Signature �j"_���j_,.�:i--�� Date � .._..,1_C._� 1. � <br />Please print this form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation from a <br />school of massage therapy including proof of a minimum of 600 hours in successfully completed course work as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Malce checks payable to: City of Roseville <br />